Renal Artery Stenosis Clinical Presentation

  • Author: Bruce S Spinowitz, MD, FACP; Chief Editor: Vecihi Batuman, MD, FACP, FASN   more...
 
Updated: Nov 8, 2011
 

History

Patients with documented or possible renovascular hypertension may experience progressive azotemia as a consequence of the renal ischemia and/or the persistence of significant hypertension. Refractory hypertension (ie, poor control of blood pressure despite treatment with 3 or more antihypertensive agents) may occur.

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Physical

The strong association of RVD with generalized ATH indicates that any typical findings associated with cerebrovascular (eg, carotid bruits, old cerebrovascular accident, transient ischemic attack), cardiovascular, or peripheral vascular disease occur frequently in patients with RVD. Abdominal bruits are highly specific for RVD when heard over the flank and are back-and-forth in nature (ie, present during both systole and diastole).

Patients with ischemic RVD present with one or more of the following clinical, historical, or diagnostic scenarios:

  • Azotemia occurs in patients with peripheral vascular occlusive disease, carotid or coronary artery disease, and other signs of ATH.
  • Sudden worsening of hypertension or renal function may occur.
  • Acute renal failure or decreased renal function after antihypertensive therapy, especially with ACE inhibitors or angiotensin receptor blockers, may occur; an increase in serum creatinine levels of more than 15% in this setting is strongly suggestive of a high incidence of RVD.
  • Unexplained renal insufficiency may develop in elderly patients.
  • Congestive heart failure may occur with poor control of hypertension and renal insufficiency in the absence of a significant decrease in ejection fraction (the so-called flash pulmonary edema).
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Causes

Risk factors associated with ischemic renal disease (IRD) are as follows:

  • Hypertension: Of patients with IRD, 35% can be normotensive.
  • Advanced age: Numerous cases occur in persons aged 60-69 years. Incidence increases in persons older than 70 years.
  • Renal insufficiency
  • Extrarenal ATH
  • Diabetes mellitus
  • Smoking
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Contributor Information and Disclosures
Author

Bruce S Spinowitz, MD, FACP  Clinical Professor of Medicine, Weill Medical College of Cornell University; School of Medicine; Associate Chairman, Associate Director and Attending Physician, Department of Medicine, Division of Nephrology, New York Hospital Medical Center Queens; Associate, Nephrology Associates, PC

Bruce S Spinowitz, MD, FACP is a member of the following medical societies: American College of Physicians, American Society of Nephrology, International Society for Peritoneal Dialysis, International Society of Nephrology, and Renal Physicians Association

Disclosure: AMAG Pharmaceuticals Grant/research funds Independent contractor; Amgen Grant/research funds Independent contractor; Affymax Grant/research funds Independent contractor

Coauthor(s)

Joanna Rodriguez, MD  Fellow, Department of Internal Medicine, Division of Nephrology, New York Hospital-Queens

Disclosure: Nothing to disclose.

Specialty Editor Board

Donald A Feinfeld, MD, FACP, FASN  Consulting Staff, Division of Nephrology & Hypertension, Beth Israel Medical Center

Donald A Feinfeld, MD, FACP, FASN is a member of the following medical societies: American Academy of Clinical Toxicology, American Society of Hypertension, American Society of Nephrology, and National Kidney Foundation

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eleanor Lederer, MD  Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD is a member of the following medical societies: American Association for the Advancement of Science, American Federation for Medical Research, American Society for Biochemistry and Molecular Biology, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation, and Phi Beta Kappa

Disclosure: Dept of Veterans Affairs Grant/research funds Research

Rebecca J Schmidt, DO, FACP, FASN  Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine

Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, and West Virginia State Medical Association

Disclosure: Renal Ventures Ownership interest Other

Chief Editor

Vecihi Batuman, MD, FACP, FASN  Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology

Disclosure: Nothing to disclose.

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